The Study of Claim Controversy Over Group Health Insurance in Taiwan

• Main Authors: Chou, Yi -Hsin, 周羿妡
• Other Authors: Hao, Chung-Jen
• Format: Others
• Language: zh-TW
• Published: 2008
• Online Access: http://ndltd.ncl.edu.tw/handle/88071289574787028127

碩士 === 淡江大學 === 保險學系保險經營碩士在職專班 === 96 === With the development of Taiwan society, the demand of health insurance by the nationals has increased in recent years. The demand of commercial insurance has not decreased due to the implement of National Health Insurance. In contrast, the demand of commercial insurance has been increased. Within all types of health insurances, group health insurance can provide the basic cover at limited price for employees in enterprises. What consumers concern the most is the quality of the claims services of insurances. This study attempted to assist the insurance industry to reduce the controversy of customer claims, and satisfy customer demands; meanwhile, to help the insurants who have purchased group health insurance to be able to obtain proper cover. This study took the frequent disputes of group health insurance while being claimed as the main stream and utilized the method of individual in depth interview and exchanged ideas with the high-level supervisors who are representatives of insurance industry to observe how insurers handle these disputes. We concluded some directions from the finding of the study for insurance industry to use as reference. These conclusions are as follow: 1.When an insurance company underwrites group health insurance, the average loss rate is usually considered as the main measurement instead of the individual condition of the insurants. As long as the claim experiences are adequate, and that the insurants have notified the general condition in advance and the profit after calculation is acceptable, the insurance company usually would promise underwriting. 2.The underwriting process of group health insurance is easier than general personal insurance, so the insurers would pay more attention on adverse selection. In general, the institutions which have no persistent employers or those operating in membership would not be underwritten because the quality of the insurants is diverse and the loss rate is hard to evaluate. 3.Insurers would raise the price or limit the claim conditions to reduce the underwriting risks when new institutions insure. In addition, insurers would utilize experience dividend to tempt the insurant to control their participant’s quality. 4.The moral risk management of group health insurance is the statistic analysis on abnormal events. The analysis can reveal whether the events centralize to certain region, medical institution or specific medical care mode. Thus, the insurers can trace the individual case to reduce improper claims. 5.When the insurant has multiple diseases and one of the diseases is on the list of exceptions, this disease can be deducted from the benefit. If there is difficulty to prove a certain disease is exception or to prove the cause and effect relation between the multiple diseases and exceptive disease, the insurer can not declare the exception responsibility.